Psychological Interventions for the Management of Chronic Pain

Several psychological factors have been established as having an impact on pain.

The following article is part of conference coverage from the PAINWeek 2018 conference in Las Vegas, Nevada. Clinical Pain Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in pain medicine. Check back for the latest news from PAINWeek 2018.

LAS VEGAS — Ravi Prasad, PhD, clinical associate professor of anesthesiology, perioperative and pain medicine and associate chief of pain medicine at Stanford University, sought to highlight the main features distinguishing chronic pain from acute pain, as well as the importance of interdisciplinary approaches to chronic pain management in a presentation given during the 2018 PAINWeek conference, held September 4-8.1

Several psychological factors have been established as having an impact on pain. These factors include depression, which was shown to increase the risk of developing chronic pain, and chronic back pain. Adverse childhood experiences including physical or emotional neglect, recurrent emotional or physical abuse, and sexual abuse were found to be associated with a lifetime diagnosis of nonspecific chronic pain and chronic pelvic pain.

Depression, anxiety, inadequate coping abilities, and preoperative somatization all have been associated with poor pain outcomes after lumbar surgery.2 “Some pain conditions are primarily due to psychogenic factors but virtually all can be influenced by psychological factors,” noted Dr Prasad.

Dr Prasad established a parallel between characteristic features of chronic and acute pain. In acute pain, avoidance helps to reduce the insult, whereas chronic pain is characterized by a fear-avoidance cycle. While the pathways for acute pain are well characterized, the etiology of chronic pain is multifactorial, with many underlying factors often unknown. The treatment course for acute pain has a clear end point and involves the use of medications and frequently immobilization, while there is no clear end point for chronic pain, immobilization is rarely recommended, and medications should be taken with caution.

As is the case for other chronic health conditions, there is no cure for chronic pain, and pain management should focus on improving the patient’s quality of life and functioning. In chronic pain psychology curricula, patients are taught basic pain and stress neurophysiology, and are then provided with tools to learn how to pace activities, relax, improve their sleep, identify common environmental stressors, and develop stress management techniques and assertive communication skills. Patients are also instructed how to establish a flare contingency plan.

Relaxation techniques such as breathing exercises can activate the parasympathetic nervous system, in addition to providing a distraction from the pain. Cognitive restructuring aims to shift a patient’s thoughts from “there is nothing I can do about my pain” or “my life is terrible” to “I can practice self-management skills” or “life may be terrible now, but I know this flare will end.”

A 2014 systematic review of multidisciplinary biopsychosocial rehabilitation interventions for the management of chronic low back pain (>3 months; 41 randomized controlled trials; n=6858) found that such programs were more effective than unimodal or standard care in reducing pain and disability.3

Growing evidence also supports the effectiveness of biofeedback in migraine and of mindfulness-based stress reduction and acceptance and commitment therapy for the management of chronic pain.

Disclosure: Dr Prasad is an advisory board member for Bicycle Health and Mission LISA (Lumina Analytics).